Dr. Rachana Reddy
Consultant Obstetrician, Gynecologist & Fertility Specialist
The Family Tree Hospital, Tirupati
She is 34. Her sister-in-law is pregnant. Again. Her mother-in-law has stopped looking her in the eye. Her husband says nothing at the dinner table. Five years of marriage. Three IUI cycles. One miscarriage. And a savings account that is now twenty-two thousand rupees lighter every month, drained by hormone injections she hides in the back of the fridge.
She is not alone.
She is one of an estimated 33 to 34 million couples of reproductive age in India living through what doctors quietly call the country’s most invisible health crisis. The World Health Organization estimates that roughly one in six adults globally experiences infertility. India contributes a staggering share of that number. One peer-reviewed study published in the Indian Journal of Community Medicine reports that India accounts for 25 percent of the global burden of infertility, and yet the condition remains one of the most neglected reproductive health issues in the country.
Read that again. A quarter of the world’s infertility burden sits inside our borders. And almost no one is shouting about it.
The Numbers India Refuses to Look At
The most rigorous data we have comes from the National Family Health Survey, the largest health dataset in the country. Analysis of NFHS-5, conducted between 2019 and 2021 across nearly half a million currently married women, found that primary infertility affects 18.7 per 1,000 women among those married for at least five years and currently in union. The burden is uneven. Goa, Lakshadweep, and Chhattisgarh carry the heaviest load, while northern states show their own complicated patterns where high fertility and high secondary infertility coexist.
In the urban metros, the picture is shifting fast. Reports from 2025 to 2026 indicate that Bengaluru and Mumbai have seen a 25 percent increase in women seeking fertility treatment after the age of 35. Career, financial stability, and delayed marriage are pushing first-time parenthood well past biology’s optimal window. The body does not negotiate with ambition. Egg quality and quantity drop sharply after 35. By 40, the natural monthly conception rate is roughly five percent.
The Crisis Nobody Wants to Discuss: Male Infertility
For decades in India, infertility was treated as a female problem. The wife was sent to the doctor. The husband sat outside. That convenient lie is now collapsing under the weight of evidence.
A landmark systematic review published in Reproductive Biology and Endocrinology, pooling data on more than 13,000 Indian men across 37 years of research from 1979 to 2016, found something disturbing. Pooled analysis showed significant declines in sperm concentration and normal morphology among Indian men. Earlier work from south India, comparing infertile men between 1993 and 2005, painted a brutal picture. Sperm count fell by roughly 30 percent, motility by 23 percent, and normal morphology by 51 percent across just over a decade.
The trend has continued globally. A 2025 analysis of three decades of Global Burden of Disease data found that India recorded the steepest rise in male infertility in all of South Asia, with disability-adjusted life years up nearly 56 percent and prevalence up nearly 59 percent between 1990 and 2021. The most affected age band was men between 25 and 29 years. The age when most Indian men assume they are at peak virility is now the age at which their fertility is collapsing fastest.
Honesty matters here. Not every Indian study agrees. A more recent 17-year analysis from a single southern Indian laboratory, published in 2025 with over 12,000 semen samples, found no significant temporal decline in sperm concentration, motility, or morphology between 2006 and 2022. The science is contested. The direction of evidence, however, is not flattering.
What is Actually Causing This
The drivers are unglamorous and entirely Indian.
Delayed marriage and parenthood. Endocrine-disrupting chemicals in air, water, and food packaging. Chronic workplace stress that wrecks the hypothalamic-pituitary-gonadal axis. Obesity. PCOS, which now affects roughly one in five reproductive-age Indian women. Untreated genital tuberculosis. Untreated postpartum and pelvic infections in rural India that silently scar fallopian tubes. Smoking. Alcohol. Sedentary lives. Studies in Delhi have found that sperm motility in healthy young men temporarily drops on days of poor air quality. The air our men are breathing is making them less fertile.
The Cost of Hope
When couples finally walk into a fertility clinic, they meet the second crisis. Money.
The Indian IVF market was valued at around 900 million US dollars in 2024 and is projected to nearly double to 1.8 billion by 2029. Roughly two lakh IVF procedures are now performed in India every year. A single IVF cycle in India typically costs between Rs. 1.25 lakh and Rs. 3 lakh, and most couples need more than one cycle. Health insurance does not cover infertility treatment in India. The financial weight falls entirely on the couple, often the wife’s parents, often dowry-adjacent family money no one wants to talk about.
The Assisted Reproductive Technology Regulation Act of 2021, which came into effect in January 2023, was meant to bring order to a fragmented private sector. Whether it will deliver patient protection or merely paperwork, the next five years will tell.
The Commercial Trap
Here is the part I find hardest to write as a clinician. Many fertility clinics in India today are commercially driven. Couples walk in with a simple problem and walk out booked for IVF before basic workup is complete. That is not medicine. That is business dressed up as medicine.
A couple presenting in their first year of trying does not need IVF on visit one. They need an honest hormonal evaluation, ovulation tracking, tubal patency testing, and the husband’s semen analysis on the same day. They need to be told that lifestyle changes, weight optimization, and timed intercourse can resolve a meaningful share of cases. They need ovulation induction. They need IUI when indicated. IVF and ICSI exist for the couples who genuinely require them, not as a default starting point.
What the Stigma Costs
In parts of Tamil Nadu, infertile women are still called “maladi” and excluded from auspicious gatherings. In Bihar, untreated postpartum infections continue to cause tubal blockage that is entirely preventable. The cruelty is not the disease.
The cruelty is the silence.
What Couples Need to Hear
Three things said plainly.
Infertility is a medical condition, not a moral failing or a karmic punishment. Both partners must be evaluated together from day one, because in roughly 40 to 50 percent of cases the male is contributing to the problem. And earlier is always better. Twelve months of trying without success at any age, six months if the woman is over 35, is the threshold to walk into a fertility consultation. Not three years. Not five. Not when the in-laws stop talking to you.
The science is on your side. The clock is not.
Dr. Rachana Reddy is a Consultant Obstetrician, Gynaecologist and Fertility Specialist at The Family Tree Hospital, Tirupati. The hospital offers fertility evaluation, ovulation induction, in-house IUI, and ART Act 2021 compliant coordinated pathways for IVF and ICSI when clinically indicated. Appointments: 8186883388.